pathological features of hypertrophic obstructive ...idiopathic hypertrophic subaortic stenosis, or...

British HeartJournal, I975, 37, 305-3I2.

Pathological features of hypertrophic obstructivecardiomyopathy (HOCM) in the elderly

Ariela Pomerance 1 and M. J. DaviesFrom the Department of Histopathology, Northwick Park Hospital, Harrow; and theDepartment of Pathology, St. George's Hospital Medical School

The pathologicalfindings and available clinical data in I.5 necropsy cases ofHOCM, aged over 6i years, are

reported. Three patients were in the eighth decade and 4 in the ninth; 8 were women. Five cases presented as

sudden death, 2 died in congestive cardiac failure, and 7 died of unrelated conditions and HOCM was an

apparently incidental postmortem finding.Compared with cases under 6o years, the hearts of the elderly patients were heavier and less likely to show

typical asymmetrical hypertrophy, the free wall of the left ventricle also being thickened in two-thirds of thecases over 6o years. Most of the elderly cases showed a distinctive band offibrous thickening over the upperpart of the interventricular septum. This lesion had a 'mirror image' relation to the lower part of the aorticsurface of the anterior mitral cusp, with the histologicalfeatures of afriction lesion. It appears to be a morpho-logical expression of the systolic contact of anterior mitral cusp and interventricular septum seen on cineangio-graphy and thus diagnostic ofHOCM. Onceformed, thefibrous band appears to persist even if the obstructiveelement disappears. It is, therefore, a valuable diagnostic feature indicating a diagnosis ofHOCM in an agegroup where the morphology is usually not the classical asymmetrical form and in which this diagnosis isusually not considered.

Hypertrophic obstructive cardiomyopathy (HOCM,idiopathic hypertrophic subaortic stenosis, orasymmetrical septal hypertrophy) is now a well-recognized condition associated with sudden un-expected death as well as a cause of clinical cardiacdisease. Young and middle-aged patients havepredominated in the extensive literature which hasaccumulated following the descriptions of Brock(I957) and Teare (I958), and it is not yet widelyappreciated that HOCM is also not uncommon inthe elderly and may be apparently of no clinicalsignificance.

In a recent review of some morphological featuresof HOCM (Davies, Pomerance, and Teare, 1974)we found that I4 of the 47 hearts studied were frompatients over 6o years, 6 being over 70. In the presentcommunication we present clinical and pathologi-cal findings in these cases and a further case in an84-year-old woman, compare them with those inyounger patients, and emphasize a morphologicalfeature which provides a useful diagnostic pointer inReceived 12 August 1974.1 In receipt of a grant from the British Heart Foundation.

an age group in which the diagnosis ofHOCM mayeasily be overlooked.

SubjectsThe I5 cases all came to necropsy in London and theHome Counties area between I965 and 1974. In 2 cases adiagnosis of HOCM had been established in life bycatheter studies and left ventricular cineangiography.These patients and 4 others died suddenly, though in onecase death had been preceded by episodes of left ventricu-lar failure. Two patients, both over 8o years, died ofcongestive cardiac failure, and in the remaining 7 casesHOCM was an apparently incidental necropsy finding. Afamily history suggesting heart disease was present in Icase only (Case 7). However, only 2 cases had been fullyinvestigated and the negative family histories in theremaining I3 cases were based on possibly incompletehistories taken on admission to geriatric or acute surgicalwards, or obtained by the coroners' officers in cases ofsudden death.The pathological diagnoses of HOCM were initially

made on the macroscopical features detailed in ourearlier study (Davies et al., I974), i.e. obvious leftventricular hypertrophy, either asymmetrical or, if

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306 Pomerance and Davies

FIG. I Opened left ventriclefrom Case I, a 72-year-old woman who died of septicaemia following chole-cystitis. The entire free wall shows hypertrophy and aprominent bulging (incised) of the upper interventricu-lar septum is present. A broad band of endocardialfibrous thickening with well-defined lower edge is seenon the upper part of the septum.

symmetrical, accompanied by the characteristic septalsubaortic fibrous band illustrated in Fig. I, 3, 4, and 5.Typical histological changes, as shown in Fig. 2, weredemonstrable in I3 cases, though examination of severalblocks was often necessary. In the remaining 2 cases,diagnosis was made from photographs taken to record asubaortic septal fibrous lesion, whose significance, at thetime of necropsy, had not yet been recognized by us. Inthese cases only a single septal block, taken through thefibrous band, was available for review.The clinical and pathological data are summarized in

the Table and representative cases reported in greaterdetail below.

Case I: HOCM as in incidental postmortemfindingA 72-year-old woman was admitted with a 2-weekhistory of diarrhoea and vomiting. On examinationshe appeared collapsed, her blood pressure was I00/50mmHg (I3.3/6.7 kPa), and she had right-sided ab-dominal tenderness. She failed to respond to resusci-tative measures. Three years previously she had com-plained of mild chest pain on exertion. Blood pressurethen was I50/8o mmHg (20.0/io.6 kPa), a soft pan-systolic murmur was noted at the left sternal edge, and

FIG. 2 Section of septal myocardium from Case I, showing the disorganized architecture,fibrosis, large thick abnormally branched myofibres, and 'whorl' formation typical of HOCM.(Haematoxylin and eosin. x 6i.)



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Pathology of HOCM in the elderly 307

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V.

go,

F I G . 3 Section through the subaortic band at its lower(apical) part, showing the superficial localization ofthe fibrosis and the valve-like arrangement of densecollagen, scanty elastic fibres, and endothelializedloose connective tissue (Case I). (Elastic van Gieson.X 14.)

an electrocardiogram showed atrial fibrillation andchanges suggesting ischaemia in the left ventricular leads.She was treated with digitalis, returned to normalrhythm, and remained well until her final admission.Necropsy showed severe acute cholecystitis with

staphylococcal empyema of the gallbladder and earlyperitonitis. The heart (Fig. i) was enlarged, weighing535 g, and showed pronounced left ventricular hyper-trophy involving the entire free wall but most prominentin the upper part of the interventricular septum. A con-

spicuous band of white endocardial thickening approxi-mately I.5 cm deep was noted on the hypertrophiedseptum about o.5 cm below the aortic valve base. Thishad a sharply defined lower (apical) margin and on

superimposing the anterior mitral valve cusp (seen re-

flected in Fig. i) on the interventricular septum it wasapparent that the subaortic band and aortic surface of themitral cusp were mirror-images of each other. Themitral cusp also showed a minor degree of flat whitethickening of its distal part of its aortic aspect. Theposterior mitral cusp and other valves were normal. A

pronounced degree of calcified atheroma was noted butthere was no macroscopical myocardial fibrosis ornecrosis.

Microscopy of blocks from the thickened septumshowed areas of disorganized myofibre architecture, withshort broad abnormally branched fibres interrupted byfibrous tissue and occasional groups of fibres arranged inwhorls (Fig. 2). These appearances correspond to thosedescribed by Teare (I958) and Pare et al. (I96I) in theircases of sudden death in young adults and are now con-sidered diagnostic of HOCM (Olsen, 197I, I972; VanNorden, Olsen, and Pearse, 197I). The subaortic bandconsisted of superficial endocardial fibroelastic prolifera-tion, the microscopical features (Fig. 3) being indis-tinguishable from those of jet and friction lesions of moreusual aetiologies (Edwards and Burchell, I958; Salazarand Edwards, I970).

Case 7: sudden death in clinically diagnosedHOCMA 63-year-old woman, known to have had 'heart troublefor years', collapsed and died while visiting relatives inHertfordshire and postmortem examination was re-quested by H.M. Coroner. Abnormal findings werelimited to the heart, which weighed 675 g and showedconspicuous concentric left ventricular hypertrophy withmild fibrous streaking visible on the cut surfaces (Fig. 4).The right ventricular cavity was also greatly restricted bythe hypertrophied septum. Though there was nostrikingly disproportionate septal hypertrophy and theleft ventricular cavity was not disproportionately small, adiagnosis ofHOCM was indicated by the presence of thecharacteristic subaortic fibrous band corresponding tothe distal part of the anterior mitral cusp. Moderate flatfibrous thickening of the aortic surface of this cusp wasalso visible. The mitral valve ring was extensively calci-fied with a spur of calcium ulcerating through the atrialsurface of the posterior cusp near the commissure. Thiscalcification was of the common senile type and there wasno other valvular abnormality. The coronary arterieswere large, widely patent, and showed minimal atheromaonly. Microscopical findings were almost identical tothose in Case I, differing only in a slightly greater amountof fibrous tissue.

This patient had been attending the Brompton Hospi-tal and Dr. M. Honey kindly supplied the clinical sum-maries. She had initially presented, aged 55, with chestpain on exertion. She had had two uneventful pregnanciesand no relevant past illnesses. Two sibs were known tohave had heart murmurs. On examination she was inintermittent atrial fibrillation, her blood pressure wasi80/95 mmHg (23.9/12.6 kPa), and a grade 3, systolicmurmur was present in the aortic area with a grade 3non-conducted pansystolic murmur in the mitralarea.On cardiac catheterization a gradient of 95 mmHg

(12.6 kPa) was present between the aorta and leftventricle and left ventricular cineangiography showedthe characteristic appearances of HOCM. She remainedfairly well for about five years, then developed episodesof weakness and dizziness. Electrocardiogram then



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TABLE Morphological and clinicalfeatures ofHOCM in elderly patients

Case Age Sex Presentation and/or mode of death Blood pressure Systolic HeartNo. (yr) murmur weight (g)

mmHg kPa present (total)

I 72 F Acute abdomen; septicaemia from staphylo- i5o/80 20.0/I0.6 + 535coccal cholecystitis

2 76 M Chest signs; carcinoma of bronchus I8o/I00 23.9/I3.3 Not recorded 275

3 67 M Urinary tract symptoms; carcinoma of bladder I70/90 22.6/1I2.0 No record 450

4 69 M Obstructive jaundice; carcinoma of bronchus 150/90 20.0/1I2.0 + 530

5 72 F Carcinoma of bronchus I I0/70 I4.6/9.3 + 4I0

6 84 F Carcinoma of bladder No record No record 360

7 63 F Anginal pain; HOCM diagnosed 6 years I80/95 23.9/I2.6 + 675before death; sudden death

8 6I F Chest pain and sudden death No record No record 700

9 6I M Sudden death No record No record 600

I0 66 M Sudden death No record No record 6I0

II 6I M Sudden death No record No record 340

12 87 F Chronic bronchitis and congestive cardiac I60/I00 2I.3/I3.3 + 5I0failure

I3 8i F Congestive cardiac failure I00/70 I3.3/9.3 Not recorded 485

14 65 M Chest pain, not clearly related to effort; 140/70 i8.6/9.3 + 740HOCM diagnosed on left ventricularangiography; sudden death preceded byepisodes of left ventricular failure

I5 84 F Gastrointestinal tract haemorrhage; acute on No record No record 380chronic bronchitis

* Single block through subaortic band only available for review.

showed periods of asystole during transition from atrialfibrillation to sinus rhythm. The arrhythmia stabilizedafter insertion of a temporary demand pacemaker anddigoxin and propranolol. She was discharged on digoxin0.25 mg daily and no further attacks had been reportedon outpatient follow-up.

Case 8: unexpected sudden deathA 6i-year-old woman complained of chest pain after acar journey, and collapsed and died after climbing aflight of stairs. Postmortem examination showed agreatly hypertrophied heart, weighing 700 g. Apart froma slightly greater degree of left ventricular dilatation andabsence of mitral ring calcification, the appearances werealmost identical with those described for Case 7, withconspicuous hypertrophy of free wall and septum andthe characteristic subaortic fibrous band (Fig. 5). Micro-scopy also showed areas with the characteristic abnor-malities of myofibres and fibrosis seen in the previousspecimens. The valves were normal apart from the

minor thickening of the anterior mitral cusp and thecoronary arteries showed mild atheroma only.

Case 12: congestive cardiac failure, clinicallyunsuspected HOCMAn 87-year-old woman was admitted to a geriatrichospital and died with a clinical diagnosis of chronicbronchitis and congestive cardiac failure. She had ahistory of 'heart trouble for years' but no further detailscould be obtained. On admission her blood pressure wasI60/I00 mmHg (2I.3/13.3 kPa) and atrial fibrillation waspresent, together with the physical signs of congestivecardiac failure. A pansystolic murmur was noted.Necropsy was performed at the request ofH.M. Coronerby Professor D. Teare. The heart weighed 5Io g andshowed considerable left ventricular hypertrophy affect-ing mainly the septum and anterior wall of the leftventricle. The left ventricular cavity was small and atypical subaortic fibrous band was present. The valvesshowed no significant abnormality. Microscopy showed



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Pathology ofHOCM in the elderly 309

Subaortic Distribution of hypertrophy Typicalband histologypresent

+ Septum and whole free wall +left ventricle

- Septum and anterior wall +left ventricle


+ Septum and whole free wall *left ventricle

+ Septum and whole free wall *left ventricle





Posterolateral wall left +ventricle and posterior septum

+ Septum, whole free wall left +ventricle, and part of anteriorwall right ventricle

+ Septum and anterior wall +left ventricle

+ Septum and free wall left +ventricle

+ Septum and free wall left +ventricle


areas of abnormal myofibre architecture and fibrosis, asin the previous cases.

Comparison of findings with those in casesunder 60 years

HOCM in the elderly differs in presentation, sex inci-dence, extent of ventricular hypertrophy, and frequencyof a subaortic fibrous band. The condition most oftenpresents to the pathologist as a case of sudden death, andthis was so in 27 (82%) of our 33 cases under 6o years(Davies et al., 1974). In contrast, only 5 of the 15 casesover 60 years presented as sudden death and these werethe youngest cases. The largest group among the elderlypatients were the 7 cases in which HOCM was anapparently incidental finding.

Half ofthe patients over 60 years were women, in con-trast to the male predominance (82%) in the youngercases. This finding agrees with the high proportion ofwomen in the elderly patients in recent clinical reports

(Penther et al., I970; Whiting et al., I97I; Alday et al.,I973).The average heart weight was higher in the older

patients, 506 g compared with 435 g in the cases under 6oyears. The whole left ventricle appeared hypertrophiedin I0 of the IS cases over 6o years, while under 60 yearsa similar proportion, two-thirds, showed typical asym-metrical hypertrophy only; the free wall of the leftventricle was thickened in only ii cases.

Discussion

HOCM is still widely regarded as a disease of theyoung and middle-aged only. Until recently thepublished reports contained only a few isolated casereports of HOCM in elderly patients, 6o yearsapparently beingthe accepted upper limit of 'middle-age' (Sanders et al., I966; Warkentin and Korns,I967; Ewy et al., I968). However, in more recentclinical series the condition has been recorded withconsiderable frequency in the elderly. The I33patients with HOCM studied by Penther and hiscolleagues (I970) included 9 over 6o and 4 over 70years, I4 (32%) of Whiting et al.'s (I97I) 44 caseswere over 60, as were I8 per cent of Tajik, Assad-Morell, and Giuliani's (I973) 95 cases and 8 of the45 studied by Alday et al. (I973). It is clear thatHOCM can no longer be regarded as an unlikelydiagnosis in older patients. The age distribution ofthe cases in our recent pathological review (Davieset al., I974) was in agreement with those recentstudies from other countries; I4 (30%) of the 47hearts studied were from patients over 60 years and6 of those had been over 70 years.The morphology and presentation of HOCM in

the elderly differed from that usually found in youngand middle-aged patients. The hearts from casesover 60 years were heavier and more likely to havehypertrophy of the left ventricular free wall as wellas the interventricular septum, and most showed adistinctive band of fibrous endocardial thickeningover the upper part of the interventricular septum.A similar high incidence of this lesion was present inPenther et al.'s (I970) fatal cases. It was noted in all6 patients dying over 55 years, but was present inonly i of the 5 patients younger than 55. This bandis clearly related to contact with the anterior mitralcusp, a relation that can easily be demonstrated postmortem by allowing the cusp to come into contactwith the septum, when the configuration of thedistal margin of the band will be seen to correspondwith that of the distal edge of the aortic face of thecusp. Microscopically the features are identical withthose of endocardial 'pockets', jet lesions, and endo-cardial friction lesions caused by altered chordal/ventricular relation (Edwards and Burchell, i958;



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FIG. 4 Opened left ventricle from Case 7, a 63-year-old woman with clinically diagnosedHOCM who died suddenly. There is striking symmetrical thickening of the left ventricle. Atypical subaortic band is present, its lower (apical) edge a 'mirror image' of the distal part ofthe aortic surface of the anterior mitral cusp.

FIG. 5 Opened left ventricle from Case 8, a 6r-year-old woman dying suddenly and un-expectedly. The entire left ventricular myocardium is thickened and the cavity slightly dilated.The characteristic subaortic band and its relation to the anterior mitral cusp are well seen.Patchy white thickening of the rough zone of the cusp is also present.



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Pathology ofHOCM in the elderly 311

F I G. 6 Fibrous congenital subaortic stenosis, forcomparison with the subaortic bands in Fig. 1, 4, and 5.The stenosing subaortic ridge is more protuberant andsharply defined, is situated nearer the aortic base, andextends onto the aortic aspect of the anterior mitralcusp. From a 75-year-old man, known to have had an

aortic systolic murmur for most of his life.

Salazar and Edwards, I970). This lesion, therefore,appears to be a morphological expression of thesystolic contact between anterior mitral cusp andinterventricular septum which is a diagnosticfeature ofHOCM on cineangiography (Simon, Ross,and Gault, I967) and may thus justifiably be con-sidered diagnostic of HOCM when observed in theopened heart. Since it is a form of chronic frictionlesion, its frequency is likely to be related to durationof obstruction and the high incidence in olderpatients, therefore, not surprising. The greaterincidence of hypertrophy affecting the left ventricu-lar free wall, and higher heart weights in the elderlypatients are also attributable to more longstandingobstruction.The subaortic fibrous septal band of HOCM is

easily distinguished from the fibrous ridge ofcongenital subaortic stenosis which may, veryrarely, also be encountered in elderly patients (Fig.6). The latter is more protuberant, very sharplylocalized, situated nearer the base of the aortic cusps,and usually extends onto the aortic face of theanterior mitral cusp near its attached margin.

Endocardial thickening of the left ventricular out-flow tract has been noted in several of the earlierpapers on HOCM (Brachfield and Gorlin, I959;Menges, Brandenburg, and Brown, I96I; Stamp-bach and Senn, I962; Braunwald et al., I964;Kittle, Reed, and Crockett, I964; Warkentin andKoms, I967; Edwards, I965), but its distinctivefeatures and diagnostic value do not appear to havebeen fully appreciated. We have emphasized thisfinding because of its diagnostic value in caseswhere the heart does not show the easily recognizedasymmetrical hypertrophy described by Teare(I958). Once formed, the subaortic band remainsvisible even in hearts in which the asymmetry andcharacteristic small left ventricular cavity can nolonger be seen (as in Fig. I, 4, and 5). Though it isgenerally believed that cavity dilatation does notoccur in HOCM, we have occasionally noted leftventricular cavities in excess of 55 ml and these havebeen seen in patients with clinically proven disease.Our experience suggests that it is in the hearts of

elderly patients that the morphological features areleast likely to be of classical type and HOCM mostlikely to be unrecognized. Ischaemic and hyper-tensive heart disease are so commonly causes ofdeath in patients over 60 years that in the absence ofany contradictory evidence left ventricular hyper-trophy is understandably usually attributed to oneor both of these aetiologies. Where blood pressurewas known to have been normal and the coronaryarteries were free from significant narrowing,cardiac hypertrophy will probably be ascribed tocongestive cardiomyopathy unless the characteristicsubaortic band is observed and its significancerecognized.Our early awareness of the subaortic band as a

diagnostic feature of HOCM was undoubtedlyresponsible for recognition of the condition in 5 ofthe 7 elderly patients who died of unrelated diseases,without any symptoms of cardiac disease. The con-cept that hypertrophic cardiomyopathy may bepresent without apparent clinical consequences is avery recent one though the variable and often longclinical course of diagnosed HOCM is well docu-mented (Frank and Braunwald, I968; Parker, I969;Goodwin, I973; Hardarson et al., I973). However,echocardiographic studies have now demonstratedasymmetrical septal hypertrophy in asymptomaticrelatives of patients with HOCM, including peopleover 70 years (Henry, Clark, and Epstein, I973).These authors put forward the concept of a spec-trum of HOCM, ranging from severely symptom-atic outflow obstruction to asymptomatic septalhypertrophy of no apparent clinical significance.Our pathological studies support this concept, thecases reported in the present communication



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ranging from those with a known clinical diagnosisofHOCM to those dying suddenly with undoubtedpathological evidence of this condition but no knownclinical symptoms.

We are grateful to Dr. M. Honey for clinical details andpermission to include Case 7, to Dr. K. Misch for theheart of Case i, and to Professor D. Teare for those ofCases 9-i2 and I4. The example of congenital sub-aortic stenosis was kindly contributed by Dr. W.Killpack.

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Requests for reprints to Dr. Ariela Pomerance, Histo-pathology Department, Northwick Park Hospital,Watford Road, Harrow, Middlesex HAI 3UJ.



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